How Dermatologists Can Screen for Mental Health Concerns in HS

Steven Daveluy, MD, FAAD, a board-certified dermatologist at Wayne State University and a nationally recognized expert in hidradenitis suppurativa (HS), joined the Skin and Psych podcast to discuss the mental health burden associated with chronic skin disease. Daveluy outlined the psychological impact of HS and other inflammatory skin conditions, along with practical approaches for starting conversations about mental health and connecting patients with appropriate care.

Mental Health Burden in HS and Other Skin Diseases

Patients with HS face increased odds of depression, anxiety, and suicidality, Daveluy said, and similar mental health burdens are associated with eczema, vitiligo, cutaneous T-cell lymphoma, and psoriasis. Visible changes to the skin can contribute to shame or self-consciousness, while physical symptoms such as pain and itch can add further burden for patients with HS.

“A lot of our diseases have a mental health burden that comes along with them,” Daveluy said.

Daveluy also pointed to systemic inflammation as another potential contributor, noting growing evidence regarding the effects of inflammation on the brain and its potential influence on depression and anxiety risk.

Stress can further complicate the relationship between skin disease and mental health. Daveluy noted that stress is commonly reported as a trigger for HS, psoriasis, and eczema, potentially creating a cycle in which disease flares increase stress and stress contributes to additional flares.

“When people are under stress, their disease flares up, which then is terrible because it only makes you more stressed that you're flared up,” Daveluy said.

Screening Tools and Starting the Conversation

Daveluy recommended quality-of-life instruments as a low-pressure entry point into conversations about mental health. Patients can complete tools such as the Dermatology Life Quality Index or an HS-specific quality-of-life measure before seeing their clinician, providing a starting point for discussion.

“You can give a quality of life tool like the Dermatology Life Quality Index or the HS Quality of Life Tool, and have the patient fill it out before you even talk to them,” Daveluy said.

However, he emphasized that clinicians should review the results with patients rather than simply collecting the forms.

Daveluy also described an “ask permission” framework he learned from psychologist Erin Martinez, in which clinicians explicitly ask whether patients are comfortable discussing their mental health.

“We know HS can have a big impact on people's mental lives. There's increased risks of anxiety and depression. Would it be okay if we talk about your mental health?” Daveluy said.

Giving patients that choice allows them to retain control over the conversation, he explained. Even if a patient does not want to discuss mental health during that visit, asking the question can signal that the dermatologist recognizes its importance and is available to discuss it in the future.

Managing Disclosures and Building Referral Networks

Daveluy acknowledged that clinicians may hesitate to ask about mental health because they are concerned about uncovering an issue they are not equipped to manage. However, he emphasized that dermatologists do not necessarily need to treat a patient's mental health disorder themselves.

“We don't have to necessarily be the one treating their mental health disorder. We just need to have a referral network and people we can send them to,” Daveluy said.

Clinicians should be prepared to respond when patients disclose significant mental health concerns, including knowing how to triage a crisis and having psychologists, psychiatrists, counselors, or other mental health professionals available for referral. Daveluy stressed that concern about what a patient might disclose should not prevent clinicians from asking, because patients may be struggling regardless of whether the subject comes up during the visit.

Collaboration can also work in the opposite direction. Daveluy recalled treating a teenager with alopecia totalis who was struggling emotionally with his hair loss. After the patient saw a mental health professional, the psychologist encouraged the family to pursue dermatologic treatment while simultaneously addressing its psychological impact.

“We ended up being able to get him on a JAK inhibitor and get the hair back,” Daveluy said. “His confidence level—it's like night and day, how happy he is.”

Daveluy said normalizing mental health questions as a routine part of dermatology care can help patients recognize that their emotional well-being is relevant to their skin disease. He suggested framing these conversations similarly to other sensitive topics clinicians routinely address and simply checking in with patients about how they are doing.

“It's really good to normalize it,” Daveluy said.